Prevention of non-communicable diseases - challenges in the next century

Professor Ravindra Fernando was inducted as the President of the Ceylon College of Physicians by the Immediate Past President, Dr. Nanda Amarasekara at a ceremony held 1998. Sarath N. Silva, the Attorney General was the chief guest. These are the excerpts from the Presidential Address of Professor Fernando:

Source: Daily News, Saturday 28, February 1998

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Ceylon College of PhysiciansI consider it appropriate and opportune to mention briefly, the history of this college. On the 26th September 1967, a group of physicians gathered at the then General Hospital, Colombo to form Ceylon College of Physicians. The late Dr. E. M. Wijerama, Physician of the General Hospital, Colombo was elected the first President of this college. Dr. L. O. Abeyratne was the first vice president. Dr. Channa Wijesinghe and Dr. N. D. W. Lionel were elected secretary and treasurer. The other council members were Dr. D. B. Goonesekara, Prof. K. Rajasuriya, Dr. E. H. Mirando, Dr. O. R. Medonza, Dr. W. D. L. Fernando, Dr. Lakshman Ranasinghe and Dr. Doris Peiris. Dr. R. P. Wijeratne was elected honorary auditor.

I had the privilege of studying under four of the founder members of the college, namely Prof. K. Rajasuriya, Professor of Medicine, Prof. Channa Wijesinghe, Professor of Psychiatry, Prof. N. D. W. Lionel, Professor of pharmacology, and Dr. Doris Peiris, consultant pathologist of the general hospital, Colombo. Unfortunately, the only forensic pathologist in the first council, much loved judicial medical officer Colombo, Dr. W. D. L. Fernando had retired a few years before we started our forensic medicine course. Dr. W. D. L. Fernando later served the college as a Vice President and as the Honorary Secretary not allowed Treasurer of the Ceylon College of Physicians Trust.

The objectives of the Ceylon College of Physicians are:

* To advance knowledge in medicine and to promote research * To promote postgraduate education in medicine and * To promote fellowship among those engaged in the practice of and research in medicine.

This year too the College, with the advice and assistance of the fellows and members, will strive to achieve these objectives. Annual Academic Sessions of the College, which will be held from 24th to 27th September this year will be the major event to advance the knowledge in medicine and to promote research. Throughout the year, College lectures, seminars and conferences will be held.

In 1971, the College held, the MRCP (UK) part 1 examination with the cooperation of the British Council and the Faculty of Medicine. This was stopped when the Post Graduate Institute of Medicine was established. The College hopes to conduct again the part 1 and part 2 examinations of the Royal College of Physicians of the United Kingdom here within the next 2 years, for the benefit of our doctors.

During my training and internship in medicine I was extremely saddened by the deaths of men and women of my age or even younger, from poisoning. I can still remember some of them. They drank poison for most trivial reasons.

Once in hospital they wanted to live, but they died because either we had no drugs or mmedical facilities. This shocking experience made me develop an interest in toxicology or the science of poisons.

In the Presidential address today, I wish to discuss a major challenge in the socio-economic and health spheres facing our country - non-communicable diseases.

Non-communicable diseases - A major challenge in the socio-economic and health spheres

Health is considered as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. Though this 1948 definition of the World Health Organization of health is criticised because of the difficulty of accurately defining and measuring "well-being", it is worth attempting to achieve this ideal.

In 1977, the World Health Assembly resolved that the main target of all countries should be to attain a level of health permitting them to lead socially and economically productive lives by the year 2000. It is quite clear that we will not attain that goal.

Many developing countries including Sri Lanka observed a decline in death rates principally due to a decrease in deaths from infectious diseases and general improvement in standards of living, especially in nutrition and sanitation. For example our death rate has fallen from 22 per 1000 population in 1945, to 5.8 in 1995.

Income growth, improvements in medical technology, public health programmes combined with the spread of knowledge about health were the four factors that caused a dramatic and unprecedented decline of mortality in developing countries such as Sri Lanka this century.

Increased income allows people to buy more food, have better housing and access to health care. Therefore, reducing poverty is an indirect investment in health. The devastating effects of ill health are greatest for the poor because they are ill more often, their income depends on physical labour and they have no savings or insurance to protect them. Therefore they may find it impossible to recover from an illness, with their human and financial capital intact.

The second factor that lead to a decline of mortality was the improvements of medical technology. Introduction of anti-bacterial drugs, vaccines, and improved diagnostic services since about 1930s immensely contributed to reduced mortality, as well as morbidity in the century.

Clean water, sanitation, food regulations and other public health measures were the third factors that helped to reduce mortality. The dissemination of health messages, the fourth factor played a key role here as well.

Health education can play a major role in the next century to spread the health messages on prevention of non-communicable diseases. Health education should start in schools, as many personal habits and life-style choices are formed early in life. Health education in schools can help young people make informed choices.

Health Education in Sri Lanka is carried out mainly by institutions like the Health Education Bureau of the Ministry of Health, members of professional bodies such as the Sri Lanka Medical Association and the Ceylon College of Physicians, and University academics.

Although it is not possible always to assess qualitatively the success of health education activities, wide acceptance of immunization in children, and of western medical treatment for snake bites, are just two success stories in Sri Lanka.

The continuous changing patterns of mortality and morbidity over time indicate that the major causes of disease are preventable.

There are four levels of prevention corresponding to different phases in the development of a disease. They are primordial, primary, secondary and tertiary.

Although primordial and primary prevention have the most to contribute to health, all are important and complementary.

Conditions leading to causation of a disease in a population or a selected group is considered primordial prevention. The aim is to avoid the emergence and establishment of the social, economic and cultgural patterns of living that are known to contribute to an elevated risk of disease.

For example, avoidance of a diet high in saturated animal fat by a population will reduce the incidence of coronary heart disease. Comprehensive policies to discourage smoking, and programmes for the prevention of hypertension and to promote regular physical activity are also methods of primordial prevention.

Primary prevention aims to limit the incidence of disease by controlling causes and risk factors. Examples of primary prevention activities include lowering cholesterol levels, reducing urban air pollution, use of condoms in the prevention of HIV infection, stopping smoking and wearing seat belts.

It is now evident that passive smoking is also harmful. People who have never smoked have a 30% increase in risk of coronary heart disease and 24% increase in risk of lung cancer, if they live with a smoker.

The aim of secondary prevention is to cure patients and reduce serious consequences by early diagnosis and treatment. Examples of secondary prevention in the area of non-communicable diseases are blood pressure measurements and treatment of hypertension in the middle-aged and elderly, and screening for cancer of the cervix, or diabetes mellitus.

Tertiary prevention is aimed at reducing progress of or complications of established disease. Physicians have a major role to play here because it consists of measures intended to reduce impairments and disabilities, minimize suffering caused by departures from good health, and promote patients' adjustments to incurable conditions such as strokes, blindness and disabling head and spinal injuries.

Health expectancy is more important than life expectancy. As people live longer, the risk of non-communicable disease grows. The World Health Report 1997 describes some of the hazards of living longer.

* Of more than 15 million deaths from circulatory diseases in 1996, 7.2 million were caused by coronary heart disease, 4.6 million by stroke, 500,000 by rheumatic fever and rheumatic heart disease, and 3 million by other forms of heart disease.

* An estimated 691 million people have high blood pressure.

* There are some 6 million deaths from cancer each year, half are them due to cancers of the lung, stomach, colon-rectum, liver and breast.

* New cancer cases in developing countries are expected to at least double in the next 25 years.

* Tobacco causes 3 million deaths a year. Smoking accounts for one in seven cancer deaths.

* The number of people with diabetes is expected to more than double from 135 million now, to 300 million by 2025.

Later death is of course a benefit, but it is essential to reduce the suffering and disability that longer life often brings. It is said that "Increased longevity without quality of life is an empty prize".

In 1996, the state spent Rs. 11,421.6 million on the health sector. Of this, 77% was on maintenance of health activities while the balance was on new investments.

The Central Bank report in 1996, recognizing that non-communicable diseases such as heart diseases and cerebrovascular diseases have emerged as the leading causes of death in recent years, commented on the necessity to allocate more resources on preventive health care.

However, the Annual Health Bulletin of 1996 showed that only 17% of the total health budget was spent on community health services which should play a major role in preventive health.

Considering the existing resource constraints, catering to the ever increasing demand for curative health facilities and meeting the increasing commitment on preventive health care will be the major challenge Sri Lanka is facing in the next century.

I wish to highlight some of the preventable non-communicable diseases and the challenges Sri Lanka will face, whether it remains a democratic socialist republic or becomes a union of regions, in the next century.

In-patient morbidity and mortality data are collected routinely from government hospitals, through a return based on the Basic Tabulation List of the International Classification of Diseases. The data for 1996 excluded the districts of Killinochchi and Mullaitivu.

Statistics in 1996 showed that ischaemic or coronary heart disease was the leading cause of death amounting to 3109 or 10.6% of total deaths.

There were 2792 deaths from cerebrovascular diseases, 2505 deaths from diseases of gastrointestinal tract, 2502 deaths from poisoning, 2395 deaths from pulmonary circulation and other form of heart disease, and 2087 deaths from cancer.

Most of these diseases and conditions, and therefore most of the deaths in some groups were preventable.

I wish to consider coronary heart disease first, as it is the leading cause of death in our hospitals. At least here, we are comparable to industrialized, affluent countries.

There is definite evidence that coronary heart disease is preventable, because some of the risk factors can be controlled, avoided or treated. Although it is stated that the most important predictor who gets coronary heart disease is who the individual's parents were, there is an important environmental component that interacts with genetic predisposition.

Some of the well known risk factors for coronary heart disease are high plasma cholesterol and low density lipoproteins, raised blood pressure, obesity, diabetes mellitus, intake of saturated fatty acids, smoking, high alcohol consumption and stress.

Therefore, it is necessary to develop strategies to prevent the rising incidence of coronary heart disease in Sri Lanka. There are well recognized approaches identified by international studies we can modify and implement, considering the constraints we face.

The prevalence of diabetes in Sri Lanka is about 5% among the urban population aged 31 to 64. In rural areas it is about 2%. When we consider the frequency we detect new diabetics in our clinics, we sometimes wonder whether even these alarmming figures are underestimates.

The prevalence of diabetes is expected to increase and the next century will see our elderly population suffering from more and more heart attacks, strokes and poor vision as a direct result of diabetes.

Studies by Prof. Devaka Fernando have clearly shown the unsatisfactory nature of management of diabetes in Sri Lanka. For example, in the diabetic clinic in the National Hospital of Sri Lanka, a single medical officer spends just over 2 minutes for each patient, no screening was performed for diabetic eye disease (diabetic retinopathy), urine not tested for kidney damage (diabetic nephropathy) and no information was provided to educate the diabetics.

Prof. Fernando has suggested the establishment of diabetes health care teams consisting of a physician, a nurse educator and a dietician, at least at tertiary level hospitals like the National Hospital of Sri Lanka. Such teams could provide comprehensive high standard diabetic care and educate the patients to prevent further complications.

The authorities will say this is a costly exercise without assessing all the savings such teams will make in preventing coronary by-pass surgery, stroke management, kidney disease and eye surgery.

More than half the young children who die in developing countries are malnourished. This does not mean that they starve to death, but that poor nutrition lowers their resistance to killer diseases.

It is at the stage when the human body is developing that malnutrition has its most severe effects. Apart from the 6.6 million malnourished children under five who die each year, 174 million more are underweight and 230 million have stunted growth.

Improvement of nutrition in adults and children is a major challenge that we face. With all the commendable achievements we can be proud of in the health sector, nutrition remains a grave health concern.

Four main types of malnutrition are the most damaging. They are protein energy malnutrition, iron deficiency, iodine deficiency and vitamin A deficiency.

Protein-energy malnutrition

This is a lack of essential protein and energy from carbohydrates. A malnourished mother is likely to have a baby with low birth weight, while children with protein-energy malnutrition do not grow as well as others. This kind of malnutrition is an underlying cause of almost one-third of deaths among children under five years.

Iron deficiency

This is the commonest type of micronutrient malnutrition causing anaemia, especially in women of reproductive age and young children. Many women spend much of their lives short of iron but during pregnancy, when the body needs extra supplies, iron deficiency can cause extra harm. It increases the baby's risk of low birth weight, anaemia and protein-energy malnutrition and lowers the mother's chances in case of haemorrhage or sepsis at childbirth.

Iodine deficiency

This is a public health problem in 118 countries. As a result, at least 30,000 babies are stillborn each year and more than 120,000 are born mentally retarded, physically stunted, deaf-mute or paralysed. The answer is to iodize salt supplies and Sri Lanka did just that a few years ago, in spite of some unwarranted criticism.

In the Sir Marcus Fernando oration I delivered in 1990, I highlighted some of these nutritional deficiencies in tea plantation women in the Nuwara Eliya district. 12% of the 149 women examined had goitres, while one was clinically hypothyroid. I am pleased that the recommendation to provide iodized salt made by me, and many other since sixties, was implemented.

Anaemia was detected in one third of these plantation women. Anaemia not only contributed to symptoms such as weakness and tiredness, it also reduced efficiency at work leading to reduced work output, affecting their income. Much more alarming is that anaemia has contributed to high maternal deaths among women.

Vitamin A deficiency

One child in every four in developing countries is at risk of vitamin A deficiency. One in five children with the deficiency is at increased risk of death from common infections, and one in 50 is blinded or suffers serious sight impairment.

The latest UNICEF report mentions that from 1990 to 1994, 25% of infants were born with a low birth weight. Figures for 1990 to 1997 show that 7% of under fives were severely underweight and 38% were moderately underweight. More alarming is the fact that 16% of them showed wasting and 24% showed stunting of growth indicating gross malnutrition. The so called "trickle down" effect of the open economy or free market economy, and the reduction or abolition of subsidies for the sake of so called economic growth has clearly not benefited the poor.

Cancers caused 2087 deaths in our hospitals. As common cancers occur mainly as a result of the way people behave and their life styles and habits, they are preventable. Cancer is the end result of a multistage process. There are initiating and promoting agents of cancer. We know the so-called carcinogens such as blue asbestos which cause pleural cancer, tobacco smoking which cause lung cancer, and 2-naphythyl-amine responsible for bladder cancer. Avoidance of these and early detection of cancer by screening methods can reduce the morbidity and mortality from cancer.

It is disturbing to note that traumatic injuries were the leading cause of hospitalization in 1996, amounting to 366,038 cases or 12.7% of all admissions. Although a detailed analysis of this figure is not available, the injuries must be due to road traffic accidents, occupational and home accidents, and ever increasing deliberate violence.

The decade 1986-1995 saw the deaths of 14,852 Sri Lankans on the roads. The largest group who died were pedestrians. According to police statistics over 150,000 were injured, some seriously. As expected, peoplised and private buses were the vehicles mostly involved in these accidents.

Reckless and high speed driving, bad roads, badly maintained vehicles and alcohol all played a part in road traffic accidents.

The road network however did not increase to satisfy the demand of these new vehicles. Therefore, the congestion of roads is clearly another contributory factor for increasing numbers of road traffic accidents.

Poor performance of the state owned rail passenger transport services, and the state and privately owned bus transport services in the last two decades, significantly contributed to the congestion of roads and the rising incidence of accidents.

When only 76 out of 134 locomotives were operational there is no wonder that the rail transport was grossly unsatisfactory. The peoplised bus companies owned 8845 buses but only 4710 or 53% operated daily. The private bus operators who account for nearly 60% of the passenger transport owned 12,000 buses, and only 75% of their buses operated daily.

When considering traumatic injuries, it is indeed unique that the first volume of the Transactions of the Ceylon College of Physicians carried a 20 page article on "The Role of Physicians in Road Safety" written by the then Chief Medical Officer, Ceylon Transport Board and member of the Permanent Commission, International Association Occupational Health, Dr. I. S. M. Fernando. He concluded his article by stating that "organized team work by people in many disciplines such as Educators, Engineers, Physicians, Psychologists and Enforcement Officers is necessary for effective prevention of road traffic accidents".

It is indeed tragic that even after 3 decades nothing definitive has been done to reduce the morbidity and mortality from road traffic accidents in Sri Lanka.

Physicians alone cannot take meaningful steps to reduce the alarming increase of morbidity due to traumatic injuries.

The police must take adequate measures to reduce the road traffic accidents by disciplining the road users and checking the maintenance of vehicles, especially public transport vehicles such as buses, vans and three wheelers.

Road accidents are preventable. The road traffic involving a Mercedes Benz in Paris last September can be perhaps called the road traffic accident of the century. Among others this tragic accident killed Princes Diana. The three deaths, including that of Princess Diana's were totally preventable. High speed, alcohol, drugs all combined to cause their deaths. Even with all these, Princess Diana's life could have been saved, if she was wearing seat belts.

The cost of road traffic accidents to the health sector is difficult to determine but it must be in region of a few hundred millions. When these victims are admitted to private hospitals they claim hospital expenses through their private health insurance schemes or the vehicle insurer. The state must devise a system of charging such patients who can claim the expenses when they are treated even in state hospitals. This will enable to recover cost of care of some patients, admitted especially to the National Hospital of Sri Lanka, and other tertiary hospitals.

Violence in all its forms has increased dramatically in recent decades. It is estimated that world over around 300,000 people are murdered and 800,000 more kill themselves each year. During 1993, at least 4 million people died as the result of intentional and unintentional injury (8% of all deaths).

In Sri Lanka, the decade 1987 to 1996 had 25,277 homicides. This figure includes the unfortunate years of the JVP uprising where 4173 homicides were recorded in 1988, and 8127 were recorded in 1989. If we consider the relatively peaceful last 5 years alone, the average homicide rate is 1487 per year.

Suicide is a deliberate act carried out by a person who expects it to result in death. Worldwide, suicide is most common among men.

Sri Lanka holds the most deserving and proud world record of one day cricket champions. Sadly, Sri Lanka also holds the world record for having the highest suicide rate in the world. We are told that the 14 year old North-East war took some 50,000 lives. Compared to this, 73,908 Sri Lankan men and women committed suicide in the last decade alone. According to the Registrar General's mortality statistics of 1995, 4283 suicidal deaths were in the 15-49 year group.

The Presidential Committee on Prevention of Suicide has prepared a National Policy and Action Plan on Prevention of Suicide. Some of the recommendations of the Committee are to restrict the free availability of pesticides and other lethal substances, phase out lethal pesticides over a period of 10 years and promote biological methods, create awareness in the community about proper handling, storage and use of pesticides and upgrade treatment facilities for management of acute poisoning. The report of this committee has identified the social and cultural factors that can contribute to suicide, and recognizes that one group takes poison as a means of responding to a short lived or minor stress.

Violence against children can take the forms of physical abuse, sexual abuse, emotional abuse and neglect. These are worldwide problems and studies suggest that the rate of child abuse and neglect of children under five years could be between 13 and 20 per 100,000 live births.

In Sri Lanka, I reported the first case of death from the battered baby syndrome in 1985, in the 'Ceylon Medical Journal'. Since then, especially in the last few years, pioneering work of two members of this College, Prof. Harendra de Silva and Prof. Niriellege Chandrasiri have highlighted the problem of child abuse in this country.

Violence against women is also a significant problem in Sri Lanka and often goes unreported. In some countries, domestic violence is the leading cause of injury among women of childbearing age, and up to 35% of women's visits to emergency treatment centres are for that reason. We have no accurate statistics on domestic violence.

In 1996, 16,500 patients were admitted with liver disease causing 2155 deaths. This is nearly a three fold increase compared to figures a decade ago. Alcohol is mainly responsible for liver disease in Sri Lanka.

The government should carefully redetermine its policies towards alcohol and tobacco. It is true that thousands are employed in activities related to alcohol and tobacco. It is true that the tax on alcohol and tobacco amounted to Rs. 5839 million and 12,833 million respectively, in 1996. The health services alone may be spending hundreds of millions to treat alcohol and tobacco related illnesses such as cirrhosis of the liver, lung cancer and coronary heart disease.

The other costs to the society from alcohol related crime and loss of productivity cannot be quantified easily. Alcohol also plays a major role in some suicides, violence against women and children, and road traffic accidents.

I mentioned earlier that a success story of health education in Sri Lanka is the acceptance of Western medical treatment for snake bites by our people. This fact is shown in the statistics of the Health Ministry. For example, in 1987 there were only 5665 hospital admissions from snake bites. In just a decade this figure increased to 27,251, almost a 500% increase! However, the number of hospital deaths remained around 150. In fact the case fatality rate decreased from 2.4% to 0.6%.

It is believed that 2 to 3 Sri Lankans die from snake bite every day. This is yet another world record and I am told that last year's Guinness Book of Records mentioned Sri Lanka as having the highest death rate from snake bite in the world.

Incidence of poisoning, which was steadily increasing in the last few decades, reached a peak in 1996. There were 70,923 admissions from poisoning including snake bites, resulting in 2502 deaths. It has to be noted that no data were available from Mullaitivu and Killinochchi districts, while even in other districts, 22% of deaths and 12.8% of live discharges were not analysed.

Pesticides are the commonest chemical substances causing poisoning. This is not surprising when one considers the fact that agriculture is the most important sector in Sri Lanka's economy, employing over half the labour force. Pesticides accounted for 21129 admissions and 1850 deaths in 1996. Pesticide poisoning was the leading cause of death in 5 districts - Hambantota, Anuradhapura, Polonnaruwa, Moneragala and Ratnapura.

To mention another world record, Sri Lanka has the highest death rate from pesticide poisoning.

Dissemination of health messages can be done through print and electronic media or by seminars and workshops. The successful preventive health messages given through print and electronic media to the public during the recent cholera epidemic are an example.

In addition to these, specialized programmes on information dissemination are useful. In Sri Lanka the only such programme is the National Poisons Information Centre in the National Hospital of Sri Lanka.

Even in developed countries like the United States of America and the United Kingdom, health care professionals usually have little knowledge of what toxic ingredients are contained in various pesticides and household chemicals. Although medical professionals are aware of chemical and adverse effects of drugs, their knowledge is limited regarding management when they are presented with an overdose.

To provide quick, accurate and tailor-made information on toxic ingredients of poisons, their chemical effects and complications, and management of patients presenting with poisoning, poison information centres or poison control centres were established in developed countries.

In 1962, an official report of the Ministry of Health of the United Kingdom recommended that, "An information service on poisoning should be set up with central arrangements for coordination." The task of implementing this was undertaken by Dr. Roy Goulding of the Department of Pharmacology, Guy's Hospital. With the cooperation of the Board of Governors of Guy's Hospital and active personal support of Professor Keith Simpson, Professor of Forenisc Medicine, Dr. Goulding established the first poison information service in the United Kingdom. This service, now known as the Medical Toxicology Unit is in the premises of the New Cross Hospital, London, and is one of the key centres in Europe.

In 1973, seven consultant physicians of the premier teaching hospital in Sri Lanka, the General Hospital, Colombo, suggested the establishment of a "Toxicology Advisory Bureau whose services should be made available to medical practitioners to render advice in cases of poisoning".

It took another 13 years even to initiate the establishment of a Poisons Information Service in Sri Lanka. This was possible thanks to a generous three year project grant I obtained from the International Development Centre (IDRC), Canada, channelled through the Ministry of Teaching Hospitals in 1986. With the technical support of the Poisons Unit, London, the National Poisons Information Centre started functioning in January 1988.

As usual, there were objections from a handful of my own colleagues for the Poisons Centre. The courageous stand of the ministry, especially of the Ministry Secretary Dr. Daya Samarasinghe, ably supported by the then minister, Sunethra Ranasihge, the Poison Centre was a reality.

This has to be mentioned because my efforts to establish a drug information service in the Poisons Centre a few years ago, to provide all information of drugs such as indications adverse effects, contraindications, dosages, safety during pregnancy and breast feeding, and cost to the patient, was unsuccessful.

The National Poisons Information Centre (NPIC) has received 4070 communications from 1988-1997. Out of this 3671 were telephone enquiries. 368 were personal visits made to the centre by either medical officers or members of public and 28 were written enquiries. There were three international enquiries by fax and e-mail.

Medical officers, other health care personnel and many other categories of individuals contacted the Centre for information.

The cost of poisoning to the health sector has not been properly assessed. One study by Prof. Nimal Senanayake and his colleagues of the University of Peradeniya has shown that an average Rs. 3875 is required to manage a patient with organophosphate poisoning. Another study by the same group calculated that Rs. 1448 is required for a snake bite victim.

These are hospital costs for medicines, investigations and staff time only. Infrastructure costs, cost to the patient an the family by way of direct costs and indirect costs due to loss of productivity have not been included.

If one considers the calculated amounts mentioned above in 1996 for patients with organophosphorous poisoning, state hospitals spent Rs. 57,714,250 and for snake bite victims Rs. 39,459,448. Considering an average of Rs. 1500 for other poisoning cases, the total hospital expenditure was Rs. 112,202,476.

Accepting certain inherent deficiencies in these calculations based on a couple of studies performed in teaching hospitals, even a 50% reduction of this amounts to Rs. 56 million to manage poisoned patients. This amounts to 0.5% of all health expenditure for 1996!

It is high time that the state and all other concerned parties take effective action to reduce the rising morbidity and mortality from poisoning. The lone struggle of the underfunded, understaffed NPIC with an insignificant annual budget will not be adequate.

It is now necessary to formulate a comprehensive programme by health authorities to educate public on prevention of non-communicable diseases. Healthy life styles, proper nutrition, prevention of accidents and poisoning, and avoidance of alcohol, tobacco and other substances of abuse should be the main themes of this ambitious programme.